Provider Demographics
NPI:1740828227
Name:ROSS, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 DESPLAINES AVENUE
Mailing Address - Street 2:UNIT 607
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130
Mailing Address - Country:US
Mailing Address - Phone:708-813-0333
Mailing Address - Fax:
Practice Address - Street 1:1037 DESPLAINES AVENUE
Practice Address - Street 2:UNIT 607
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130
Practice Address - Country:US
Practice Address - Phone:708-813-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490158101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical